She means well, but I dread the dental hygienist. The judgmental tone in her voice is probably just exhaustion; the only dentist I can afford to see has an office that’s a in perpetual spin of budget-seeking patients. I’m one of scores of people who’ll sit her the chair today, and whenever I leave, I hear someone standing at the dreaded reception desk trying to argue their way out of a bill in an embarrassed tone.

Sometimes I’m in that corner too, wheeling and dealing for a way to swing basic treatments with money I don’t have. To my shame, I often go months or even years between routine cleanings, opting to spend money on debt or bills or food instead.

Lack of dental care does more than make it easy to figure out who’s rich and who’s not. It’s also fuels serious healthcare issues and self-medication through opioids:

George Acs, director of the dental department at Chesapeake Health Care, a clinic near Salisbury, said people with oral pain and infections are inundating hospitals. Last year, more than 2 million U.S. emergency room visits were attributed to neglected teeth.

“What I am seeing is absolutely horrifying,” said Acs, who recently testified about the problem before the Maryland state legislature.

Although those hospital visits cost an estimated $1.6 billion a year, the ER is generally not equipped to fix dental problems, Acs told lawmakers. So ER doctors just medicate people with “a perpetual cycle of antibiotics and opioids.”

That cycle is feeding a nationwide epidemic of opioid addiction. Meanwhile, Higgins said, Americans’ increasing reliance on all kinds of drugs is further ruining their teeth. Many drugs cause dry mouth, which leads to more cavities. When she started her practice 35 years ago, she said, people took far fewer prescription drugs. Now patients hand her computer printouts with long lists of them.

Like it or not, it’s clear that what happens, or doesn’t happen, in the dentist’s office is worth our attention. These essential pieces look inside the tumultuous world of the American way of dental care.

Half of the American populace doesn’t have dental coverage, but money isn’t the only thing that makes it hard for poor people to take care of their teeth. Smarsh explains how growing up in poverty often puts up insurmountable barriers to dental health—and how people with “meth teeth,” dentures, and untreated dental problems get stuck in a cycle of poverty and pain because of their lack of dental care.

Common throughout those years was a pulsing throb in my gums, a shock wave up a root when biting down, a headache that agitated me in classrooms. While they looked OK, my baby teeth were cavity-ridden. Maybe it was the soy formula in my bottle when they were growing in, or the sugary cereals to which my brain later turned for dopamine production in a difficult home. Maybe it was because our water supply, whether from a rural well or the Wichita municipal system, wasn’t fluoridated. But richer teeth faced the same challenges. The primary reason my mouth hurt was lack of money.

Even someone with Medicaid coverage for dental care can have a hard time finding a dentist if they live in the country. Rural locations are less likely to have fluoridated water, reports Alison Kodjak, and they’re also underserved by dentists who can find more money and less hassle elsewhere. By the time someone does find a dentist willing to treat them, people may have gone years without treatment.

John O’Brien, a dentist and the clinic’s director of dental operations, says he sees about four or five new patients every day, and at least one of them needs more than half their teeth pulled.

When he told a 40-year-old hunter and fisherman at the clinic in Rhinelander Wis., that his periodontal disease was so bad that he needed all his teeth pulled, “He just broke down in tears,” says O’Brien.

“He couldn’t find someone in 20 years to care for his teeth,” O’Brien says. “There are just not enough dentists, so they can pick and choose who they want to treat.”

Wise, Virginia has an annual tradition—and though it takes place beneath a huge tent, it’s not a religious one. One a year it’s home to the the country’s largest pop-up clinic, Remote Area Medical, which is a lifeline for thousands of uninsured people. People camp out for days to get care, much of it dental, but they find a different kind of care beneath the tent, too—a dignity that’s all too often denied to people who can’t afford insurance.

“They treat you like you’re special,” Sandra says when I ask her why she came to the clinic for help. Sandra has worked at a Tennessee manufacturing plant for thirty-eight years, surviving several layoffs that many of her friends did not, but her company-provided health insurance doesn’t cover dental care. She previously funneled most of her pay toward caring for her husband, who recently passed away, and who after a cancer diagnosis and a heart attack was not disabled enough to receive benefits but required a lot from Sandra, both financially and emotionally. Since his death, she says, her grief has brought on a good deal of depression. She’s here at the clinic for an extraction and a filling. “These are nice people,” she says. “And they act like you’re somebody.”

If that dignity is absent in the American health care system, so too is the concept of ongoing, incremental care. Atul Gawande explains that a premium is placed on high profile, one-time treatments, to the detriment of patients who need a lifetime of care. But will doctors and dentists be able to change the system to make it available to more patients?

Like the specialists at the Graham Center, the generalists at Jamaica Plain are incrementalists. They focus on the course of a person’s health over time—even through a life. All understanding is provisional and subject to continual adjustment. For Rose, taking the long view meant thinking not just about her patient’s bouts of facial swelling, or her headaches, or her depression, but about all of it—along with her living situation, her family history, her nutrition, her stress levels, and how they interrelated—and what that picture meant a doctor could do to improve her patient’s long-term health and well-being throughout her life.

Success, therefore, is not about the episodic, momentary victories, though they do play a role. It is about the longer view of incremental steps that produce sustained progress. That, such clinicians argue, is what making a difference really looks like. In fact, it is what making a difference looks like in a range of endeavors.

It might seem like the modern dental divide is bad, but the old days of dentistry were much, much worse. Take “Painless Parker,” a charlatan who turned pulling teeth into a dog and pony show—and changed the dental profession for the better while he was at it.

While he pulled the tooth out, still for 50 cents an extraction, Parker would tap his foot on the ground to signal the band to play louder—effectively drowning out the patient’s pained screams. He still used the cocaine solution—but instead of injecting it to numb the mouth, he’d squirt it into the cavity—and that only worked sometimes, if at all. Still, Parker managed to become popular. Dental patients and visitors liked the distraction of the brass band and the rest of the circus. Thanks to the band, no one heard the moans—and everyone but the hapless patient assumed the treatment didn’t hurt a bit.

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